Integrated Care

Why a team approach works

By Dan Robbins, MD
Fellowship-trained spine surgeon

On any given day health care professionals and the public at large see multiple studies from peer review journals as well as magazine articles recounting the failings of our current fragmented medical systems.

These articles describe the usual issues that lead to poor patient outcomes, sometimes catastrophic, as well as the excessive testing and inappropriate procedures. They are linked to poor communication both on a system wide and personal basis. This is coupled with the tendencies for all health professionals to want to do something in the face of our patients' suffering. We are rapidly learning that we cannot spend our way out of intrinsic flaws in our medical system.

This is especially true in the case of spinal ailments. The literature is replete with the over diagnosis of problems linked to isolated x-ray findings and readings. I would add that when well-intentioned physicians treat "the picture" (ie. MRI as an example) they get it wrong perhaps 50% of the time. Case in point, research has shown that 40% of healthy persons over age 40, with no back pain whatsoever, have spinal abnormalities that show up on an MRI. So using an MRI to diagnose spine problems or as an indication for the need for spine surgery is often a flawed approach.

In addition, treatment of back and neck pain can also be complicated by psycho-social issues. An isolated practitioner with the technical ability to inject someone's back (referred in the medical community as a “needle jockey”) who is sent a patient without a thorough evaluation and assessment in the context of imaging is likely to receive multiple injections. For a spinal injectionist who lives with needles, but has no real training in diagnosing soft tissue strains (which represents 80% of back pain) is like the carpenter with a hammer in hand who views everything as needing a nail.

More to the point, injection procedures may be helpful at times but only as a bridge to something else, such as other non-surgical treatment options including therapy that makes the back stronger, more flexible and more resistant to future strain. Too many times, unfortunately, a solo physician operating in his single silo of care, believes incorrectly that an injection is the ultimate panacea or cure, or that a surgery is the answer. Instead, what the patient really needs is a TEAM OF SPECIALISTS, not single fragmented silos. A team of multiple specialists represents a truly INTEGRATED APPROACH to back and neck pain.

At Taconic Spine, for example, we have a fellowship-trained spine surgeon working hand-in-hand with a specialist in Physical Medicine & Rehabilitation. This PMR specialist is board-certified not only in Physical Medicine (which is the expertise in soft tissue) but also board-certified in pain medicine (which is the expertise in injection therapy). This is the best of both worlds as the patient benefits from having the expertise in soft tissue injury and non-interventional techniques, including supervision of manual therapy treatment options, combined with the same expertise of an anesthesiologist.

In a sense, instead of hiring a carpenter to build your house who only knows how to use a hammer and a nail, this PMR specialist is like hiring a carpenter who not only is proficient with hammer and nails, but also creating tongue and groove mortise joints, gluing and other advanced homebuilding techniques. You end up with a better built house by virtue of having a better trained professional.

Just as important is a spine care specialist with a full understanding of the breadth of clinically relevant findings and efficacious treatments available upon evaluating the patient. Taking both of these type of individuals and get them on the same page in the care of any given patient that presents with back pain gives that patient the best possible chance of a successful outcome.

Integrated care requires the evaluation of the whole patient with teaching that empowers the patient to understand the roles of the different players (as well as themselves) in the treatment process. The role of different treatments, including passive and active interventions linked to the individuals’ belief systems must be part of the discussion, so as to set appropriate expectations and lay out timelines for surgical options should non-surgical treatments fail.
The lack of a cohesive program with aligned expertise including a recognized array of screening tools, linked to true functional outcome measurements make it less likely one will obtain a good outcome. We all know of patients and family who can recount having had back and neck problems for years. Early intervention in the form of teaching and self directed programs can be incredibly beneficial to controlling what often can become an increasingly disturbing problem. This does not address the litany of complaints from long term problems after ill advised surgical interventions that did not include a more integrated, thoughtful workup and evaluation.

In this day and age of sophisticated technologies, we all are learning the hard way that they do not substitute or replace good clinical acumen. Integrated care in most medical programs reap benefits to both the patient and the health system. Measuring of outcomes and improved quality of life can more likely be achieved as in the airline industry with tight and clear communication. That is not obtained with an integrated electronic medical record alone. As we know with computers; garbage in garbage out.

An integrated spine care team require many assets to succeed including algorithms that help all care givers in the health system practice state of the art evidence based medicine. The standardization of therapies and their application with the ability to take the most current techniques in experienced hands brings a uniformity of message and improved outcomes. The presence of such a program in our region will hopefully enhance the development of an even better system to care for a diagnosis that touches most of us in our lifetime.

Our spine center offices serve all of Vermont, including the communities of Burlington, Bennington, Rutland, Manchester, Barre, and Montpelier, upper New York state including Saratoga Springs and Queensbury, New Hampshire and Massachusetts.

Disclaimer:

The pictures displayed in www.TaconicSpine.com are images of physicians, patients and employees who have consented to have their pictures in this website.

You might be surprised to learn that 80 percent of the time, back and neck pain is simply a result of strain or soft tissue injury. Click here to learn about the different conditions related to neck and back pain and how to relieve symptoms through treatment.

One of Vermont’s most innovative spine surgeons, Dr. Robbins specializes in minimally invasive back surgery and regularly teaches new techniques for spine surgery at clinics around the country. His medical degree was received at Howard University, followed by his internship completed at St. Vincent’s Medical Center. He received his fellowship training at the University of Hong Kong in Spine and Pediatric Surgery. Click here to learn more.

The vast majority of back problems improve on their own or with nonsurgical treatment. There are a few warning signs, however, that may indicate serious spinal problems. Weakness or numbness in a leg or arm, especially if it is severe—and it is getting worse—also points to nerve damage. Nerve damage associated with these symptoms can be permanent if not treated immediately. Numbness, pain or tingling that radiates into the arm or leg is also a source for concern and should be seen within a few days by a spine specialist.

Click here to learn more about what symptoms mean and when to see a doctor.

The vast majority of back problems improve on their own or with nonsurgical treatment. There are a few warning signs, however, that may indicate serious spinal problems. Please take a moment to view frequently asked questions that can help you understand pain symptoms.

Dr. Rob Giering specializes in developing non-surgical treatment options for back and neck pain patients, including the use of customized spine therapy techniques and spinal injections that relieve inflammation around nerve roots. These injections enable many patients to resolve their symptoms without the need for surgery. Click here to learn more.

Taconic Spine emphasizes activity as the key to relief from back and neck pain. The Vermont spine center mails out a free 36-page Home Remedy Book for back pain and neck pain with pain-relieving stretches that can be done on the living room rug while watching TV. These customized exercises make the back stronger, more flexible and resistant to injury. Click here to learn more.

New minimally invasive spine surgery tools and techniques used by the spine surgeon at Taconic Spine reduce the length of the incision and enables the person to go home quicker and have a less painful recovery.

Recognizing that spine care requires a spine center approach, Taconic Orthopaedics founded Taconic Spine in 2011 as its spine specialty center. For more than 40 years, Taconic Orthopaedics has cared for people in the Vermont region. With seven orthopaedic doctors, it is one of the largest orthopaedic groups in Vermont. It includes board-certified specialists in knee and hip replacement; joint problems; sports medicine and general orthopaedics. Click here to visit the educational Internet site for Taconic Orthopaedics.